Best nursing homes 2013 (DAJ | Getty Images)

Once your family has considered all of the alternatives and has settled on a nursing home as the right decision for Mom or Granddad, choosing the right one starts with four general principles: The ideal home will be convenient to as many family members as possible. It will provide high-quality care if Mom has a chronic condition such as dementia or physical disability. It will offer Granddad welcoming, supportive environment. And its cost will fall within a range that a combination of savings, Medicare, Medicaid, and perhaps long-term care insurance can comfortably absorb.

The first step is to assemble potential candidates. Start with geography by searching your first choice of location at U.S. News's Best Nursing Homes, to generate a list of homes and see at a glance their ratings of one to five stars in three critical respects:

  • The kind and amount of nurse staffing the home provides;
  • The home's diligence in meeting state health and safety standards;
  • The home's performance in key medical and behavioral measures, such as the percentage of residents receiving annual flu shots and whether residents get sufficient help with daily activities.

After reviewing each home's pros and cons, by the end of your online session you should have a manageable number. You can then prune the list by visiting the homes, asking tough questions, and being attentive to each home's personality and attitude toward its residents. As you narrow the list, arrange repeat trips to those remaining, at different times and on different days of the week than when you first visited.

Your loved one's safety and health trump all other considerations. If you discover that a home's online evaluation included safety and health violations, you will want to ask administrators how they were handled. The mere fact of a violation need not rule out a home. It may have earned a lower rating because of a violation that was corrected quickly—such as a low-pressure fire extinguisher that was replaced within a day—or a violation could be serious and not so easily resolved, says Tom Burke, spokesman for the American Health Care Association (AHCA), a trade group that represents long-term care providers.

Safety hazards aren't always obvious. For example, you should look for frayed carpets and other potential causes of a fall, says Barbara Glickstein, a registered nurse and co-director of the Center for Health, Media & Policy at Hunter College in New York City.

Adequate staffing is critical to a safe and healthy environment. Without enough nurses and aides, care suffers. A resident with shaky hands who doesn't get the help she needs at meals can become malnourished. An infirm resident who has to wait to get help with toileting can develop a urinary tract infection that could progress to a life-threatening blood infection or kidney failure. Staffing ratios displayed on Best Nursing Homes indicate the time nurses at different levels spend with patients on average.

One potentially valuable figure that you won't see would show staff turnover. Heavy turnover is an obvious indication of unhappy workers, whose dissatisfaction could mean worse care. The national average for turnover in 2010 was 39.5 percent for all positions within a nursing home, according to an AHCA report published last year. The federal government has plans in the works to collect and report the information but does not now require homes to show it.

Burke recommends focusing on "consistent assignment," meaning whether nurses and aides care for the same residents on most of their shifts. If residents can see the same caregivers most of the time, they can build relationships and will feel more comfortable and secure. AHCA recommends that individual staffers care for the same residents on at least 80 percent of their shifts. You should ask administrators whether their caregivers work with the same residents. Ask residents and their families, too.

Heavy reliance on temporary nurses and aides also hampers relationship-building, says Susan Lutz, project manager for AARP education and outreach. She advises asking specifically about the proportion of direct caregivers from temp agencies.

You can pick up signs that staff members respect and care about residents in the small interactions between them, Burke says. Before entering a room, for example, do nurses knock? Do staffers address residents casually and impersonally, or politely and by name?

Nursing homes that treat their residents well tend to have solid connections with the community, Lutz says. Families should find out whether homes have ongoing relationships with schools or local houses of worship. Maybe Dad can't play the piano any more, but hearing student recitals might rekindle some of that same spark.

Find out other ways the staff keeps residents occupied throughout the day. You don't want Mom in the hall in a wheelchair all day, says Sharon Brangman, division chief of geriatrics at SUNY Upstate Medical University in Syracuse, N.Y.

Don't ignore similar personal preferences and habits your loved one holds dear. Religious practices, such as pastoral care or kosher meals, could be the most important factor to your loved one, says Jennifer Brown, director of admissions and marketing for the Methodist Home and Forest Side Assisted Living, a continuing-care facility in Washington, D.C. U.S. News indicates a home's religious affiliation, if any, on its profile page in Best Nursing Homes.

In the end, a home has to be affordable. A year in a nursing home now costs an average of close to $100,000, and not all charges are obvious. Some homes, for example, tack on fees for physical therapy or dentist appointments. Medicare only pays for short stays following hospitalization, and Medicaid—which not every home accepts—requires depleting most of a resident's assets.

Regardless of the expense, you won't want to economize in ways that compromise your loved one's quality of life. The latest MetLife Mature Market Institute survey shows that choosing a shared room over a private room saves an average of nearly $10,000 a year. But if Dad values his privacy, and a home that's a little farther away can offer him his own room at a price that makes a less-convenient home more affordable, you'll probably want either to figure out a way to keep him nearby and make the higher payments, or put up with the longer drive. Why compel him to accept a roommate?

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